The onset of the COVID-19 pandemic created extraordinary new challenges for the emergency medical services (EMS) industry. Frequently shifting state and federal guidance and emerging information about the novel virus has required EMS agencies to be even more nimble in delivering care.
This is true for Empress EMS, a PatientCare EMS Solutions company, which serves New Rochelle, New York – the first epicenter of America’s COVID-19 pandemic. Empress first began monitoring for COVID-19 on February 15, 2020, as it recognized the New York City area’s high risk for the virus.
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Early in the pandemic, the 911 service provider made critical changes to its operational plans and shifted its response strategies. As 911 callers became potential COVID patients, Empress began taking extra precautions on each call by using advanced infection control technologies and processes. The increased safety precautions resulted in far longer turn-around times than normal, requiring shifts in operations.
Additionally, the region experienced a 25% increase in 911 call volume during the beginning of the pandemic, which overwhelmed the entire emergency care system — from EMS to the hospitals. Despite these challenges, Empress maintained its focus on keeping its employees and patients safe.
Westchester County: The Nation’s First Epicenter
In mid-February 2020, Empress leaders began creating operations plans that would keep its patients and employees safe, limit community spread of the virus, and allow for quick implementation should the virus take hold in its service area. Empress sourced additional personal protective equipment (PPE), including gowns and N95 masks, and began investigating additional decontamination equipment for its vehicles.
It quickly implemented additional infection control procedures, amplified training on PPE use and increased the frequency of its internal communication. The clinical team produced full-color “quick-reference guides” for COVID response and PPE use, placing them in every EMS unit and distributing them to all staff as an initial step in protecting staff and patients.
These early plans and preparations were rapidly deployed when New York’s “Patient Zero,” a New Rochelle resident, was diagnosed on March 1. New Rochelle, a Westchester County suburb north of New York City, is one of Empress’ 911 service areas.
Calming Fears with Company Communications
Fear stemming from misinformation was one of the first challenges that Empress faced at the pandemic’s onset. Information was flowing quickly from many sources, and employees were inundated with horrific news about the virus, its spread and its effects.
Empress encouraged its staff to rely on credible news outlets that reported confirmed and accurate information regarding COVID-19. It provided updates from the Centers for Disease Control and the state of New York through its internal communications channels as a way to calm fears and limit the spread of misinformation.
Empress countered misinformation about the pandemic with frequent and consistent information from the company. Empress’ main message: reassure staff the company’s key concern was — and still is — keeping patients and staff safe.
From the onset of the pandemic, Empress managers participated in daily all-call meetings, and others with supervisory responsibilities participated in a company call every six hours. In daily briefings, supervisors could ask questions, discuss key points like the effective use of PPE, relay concerns or dispel rumors.
Empress was already using email, text, and private Facebook groups to communicate with employees, but quickly recognized the need for an additional avenue for consistent communication. Other PatientCare EMS Solutions’ operations were already using a mobile app for employee communications. Within two weeks of the pandemic’s onset, Empress launched the app, providing another means of consistent information for employees.
Through the app, Empress posted daily updates with quick, easy-to-read bullet points of key information, and shared videos with training tips. Employees could access information, training, and real-time local data on COVID-19, at any time — on or off duty — which was important during the pandemic’s ever-changing environment.
Controlling the Virus’ Spread with Training and Procedures
Given the highly infectious nature of COVID-19, Empress knew that infection-control procedures were the best way to keep patients and employees safe. It had ample PPE for normal circumstances as well as a surplus, however, not knowing the longevity of the situation, significant additional PPE, regardless of the rising cost and lack of production, became necessary. Through its own relentless efforts coupled with assistance from its municipal and county clients and New York City, Empress was able to source the materials needed to protect its employees.
Empress did not wait for guidance from state or federal officials on mask mandates. Starting on March 9 — weeks ahead of federal guidance — a surgical mask was placed on every patient, employees wore a surgical mask prior to any patient contact, and all patients were triaged at arms-length for possible symptoms or exposure. Simultaneously, Empress dispatchers started screening all callers for potential COVID exposure, symptoms or travel concerns to better prepare crews.
On March 17, the Empress requirement changed to all staff wearing a surgical mask while on company property, staffing an ambulance, and at any time while wearing an Empress uniform. Screening protocols were enhanced and masks were upgraded to N95 for any patient who was suspected to have COVID, and paramedics and EMTs donned additional PPE on these calls.
“PPE has always been a normal procedure in EMS, but this new virus had so many unknowns. Our management and field staff were meticulous in protecting themselves and others,” said Daryn Baia, EMT-P, director of Clinical Services for Empress EMS. “This was a level of concern far from routine.”
PPE is only effective with proper use. Although all field staff receive training on OSHA protocol and proper PPE use during orientation and annually, Empress wanted to ensure that employees were vigilant in practicing safety protocols so they re-trained on proper use of masks, gloves, eye protection and gowns according to COVID protocols.
While training videos and handouts were helpful and easily accessible, Empress employees also participated in in-person infection control training to reinforce proper behavior. Small-group trainings, followed by one-on-one sessions with a field training officer or supervisor were held to supplement and help ensure safety in this highly contagious environment.
For the first 7-10 days after training, Empress sent a supervisor to every call that possibly had a COVID-positive patient. The supervisor supported employees by reminding them about the procedure change to don PPE before knocking on the patient’s door, step back six feet, ask screening questions before entering the residence and place a mask on every patient.
The supervisor coached employees in real-time on proper donning and doffing techniques to avoid contamination. They also documented PPE use with electronic after-action reports within minutes of a call’s completion. These after-action reports helped track possible exposure and identified employees who needed to isolate.
Higher Call Volumes, Longer Transport Times and Higher Out-of-Service Times
Empress typically handles 150,000 responses per year, but it saw a spike of 20-25% in call volume in March and April 2020. About 50% of those dispatches involved patients who matched screening questions for COVID.
Every call took longer to complete with the new infection control protocols at both Empress and at the hospitals. In addition, ambulances were taken out of service for decontamination after transporting patients who were potentially positive for COVID. Decontamination initially took upward of three hours. By investing in foggers and additional staff, Empress was able to reduce decontamination time to about 20 minutes, which is still longer than normal.
Adding to staffing demands, Empress was asked to mobilize with New York Department of Health’s COVID-19 Task Force on March 7. Empress immediately responded and provided mobile-response COVID testing, large-scale COVID testing to nursing homes, and EMS support to drive-through testing sites. Empress’ community paramedics, paramedics and EMTs helped staff the first drive-through COVID testing site, which tested as many as 1,000 people per day, in New Rochelle for two months. Empress was also asked by the CDC to write protocols for rapid nursing home response and testing based on the efficiency, skill and safety practices demonstrated during the early stages of the pandemic. These protocols were shared nationally.
The additional volume, combined with the extra time needed for appropriate care and decontamination, was unsustainable. The entire emergency care system in New York was overwhelmed and needed alternatives for treatment.
State Mandate Changes Care Model
On March 22, the state of New York mandated that ambulance service providers could not transport patients with COVID symptoms who were under the age of 65 and did not have one of the five major co-morbidities.
At that point, 65-75% of Empress’ 911 calls were related to low-level symptoms; the balance of 911 responses were essentially high acuity or critically ill COVID-related patients.
“The policy of “˜treat in place’ was formulated to mitigate the surge in call volume from the worried well and lower acuity patients so that those who truly needed medical attention could have the resources available,” said Barry Smith, MD, medical director for Empress EMS.
Most patients had seen the news with New York Governor Andrew Cuomo and understood that only critical patients should be hospitalized. However, they were worried about the illness, and they needed reassurance and direction on caring for themselves or loved ones.
Empress, needing to shift again to accommodate this change in the state’s mandated procedure, looked to its existing community paramedicine program for an example of how to successfully implement “treat in place” protocols. Paramedics and EMTs provided patients with care tips like taking fever-reducing medications to lessen the severity of symptoms and increasing the intake of fluids to stay hydrated. They also provided a toll-free number for a New York COVID Hotline to call with questions, as well as a hand-out containing important information about at-home care.
To ensure patients received the appropriate level of care, Empress intensified its quality assurance protocols to 100% of cases, completed nearly in real-time. All patients received call backs from Empress’ Community Paramedicine Team to check their health status and answer any questions. If there was a concern during the quality assurance call, the Community Paramedicine Team responded to evaluate and further assist the patient. These calls were not mandated, but Empress found that they were a valuable tool in keeping patients safe, healthy, and informed as well as determining who may actually need to be transported to a hospital for care.
Quality assurance was a clinically important step. It helped Empress screen patients for cardiac risk factors as soon it noticed an increase in cardiac arrests. Overall, cardiac arrests increased by 400% during March and April 2020, and many of the cases were tied to COVID.
“The “˜treat in place’ policy was able to take a tremendous burden off of the already overflowing local emergency departments,” said Dr. Smith. “The success of the program was driven by on the ground leadership, daily communication briefings, professionalism of the field personnel and the agency’s commitment to the community.”
Staying Safe and Healthy
The communication, training and protocols for infection control worked. More than half of Empress’ 600 employees began using the employee communication app as soon as it was rolled out.
Empress has had very low infection rates among its workforce. Only 50 people, or 8% of its workforce, tested positive between March and August 2020, a significantly lower infection rate than other agencies in the region.
“Our team’s diligence in proper PPE and continuous messaging about safety kept our infection rate low,” said Baia.
The daily impact from COVID positive employee tests on staffing has been minimal, meaning Empress and its employees remain healthy while providing top-quality care to one of the hardest-hit regions during the COVID-19 pandemic. According to data gathered by Empress and the New York City health system, Empress has transported close to 10,000 COVID patients with Westchester County and New York City to date.